Haiti Epidemic Advisory System (HEAS) SitRep: UPDATED 26 APR

Updated 1534 GMT, 26 APR 2010

Updates to the text are noted in blue.

Mission Objective.  Our objective is to identify those infectious diseases that may abruptly overwhelm the ad hoc medical infrastructure or be perceived by the Haitian public to be unusual or unexpected.  In other words, identification and prioritization of those infectious diseases that may become a crisis or disaster.

Biosurveillance Grid Status.  Formal syndromic surveillance remains limited. This is a major concern given the coming major rainy season, population shifts anticipated during the relocation process, and continued decline of the ad hoc medical response grid. There have been and will continue to be time delays between unofficial reporting of infectious disease events and official acknowledgment. 

CDC recently acknowledged limitations in current public health surveillance activities in Haiti:

• A reliable malaria surveillance system should be established as soon as possible. The system should detect cases and monitor trends, based upon laboratory confirmation of Plasmodium falciparum infection in persons with fever. This may require strengthening existing systems.
• Use of Rapid Diagnostic Tests (RDTs) at peripheral health facilities will be important to target appropriate treatment, differentiate malaria from other causes of febrile illness, and help define the local epidemiology.
• If an increase in the number of malaria cases is detected, targeted vector control strategies based on an entomologic assessment should be implemented; active case detection may be useful, including screening (using RDTs) of febrile individuals living in the same household as the index case.
• If there is a large malaria epidemic, mass RDT-screening by mobile teams of all individuals in the region of the outbreak and treatment of persons with positive tests (regardless of symptoms) may be indicated. If it is operationally difficult to obtain laboratory confirmation for each case, presumptive treatment of malaria/fever cases based on a standard case definition could be considered to reduce morbidity and mortality.
• Because P. falciparum malaria has non-specific symptoms, can be fatal, and is easily treated if therapy is begun promptly, it is important to include malaria in the differential diagnosis of febrile illnesses. Unless there is another obvious cause of illness, all cases of fever should be tested for malaria and treated based on the results.
• Entomologic assessments should be done to assess levels of insecticide resistance and to monitor mosquito abundance. The latter helps to measure the impact of vector control interventions such as larviciding, spraying, or deploying insecticide-treated materials.

Members of the HEAS community currently perform these functions.  Current metrics for the HEAS :

1. Nearly 200 individuals representing Haitian authorities, the Health, WASH, Shelter, and CCM Clusters, major NGOs, and medical personnel participate in the HEAS community reporting system. This is an increase of 20 individuals from prior report.

2. Several of the NGOs have forward-deployed medical countermeasures and checked their logistics chains based on HEAS community-driven advisories.

3. WASH Cluster has been sensitized by HEAS community-driven advisories to accelerate their hygiene campaign activity and have joined the HEAS community, introducing an integration of water / hygiene / sanitation interests with those of medical / public health. Situational awareness of infectious disease events is now shared by both groups.

The HEAS community continues to behave proactively (i.e. ahead of a potential crisis) in response to warning information, a key finding.  

Water-Hygiene-Sanitation. WASH cluster reported an observation in their 13 APR SitRep that additional displacement has occurred, with an apparent doubling of the number of camps. They are verifying this observation now. Under reporting of agencies has complicated coordination efforts. The initial planning figure for WASH's efforts was 1.1M for immediate needs. Their new estimates suggest the actual need is 2.1M. They state:

The potential doubling of the number of people in camps has obvious enormous implications – both for the WASH Cluster’s ability to be able to respond to support basic needs, but also to understand why more people are being drawn to camps (as highlighted in the last report) and if there is a way to reduce this. Currently we are not all working on the same data set.

The SAG (Strategic Advisory Group) of the WASH Cluster meet this week to discuss strategies to be able to fill these potentially enormous gaps. However, the lack of an overall humanitarian strategy presents great dilemmas for agencies of how much and how to invest in current camps.

WASH estimates as many as 60% of sites in Port au Prince have no WASH cluster presence. In Leogane, many organizations are planning to leave who were participating in water delivery, with an expected handoff to DINEPA.

Excreta disposal has accelerated, however implementation of handwashing and bathing stations have fallen behind. Absolute latrine coverage is low, however open defecation is reportedly low. It is thought people are still returning home to defecate or use plastic bags and disposing them in solid waste dumps. Solid waste disposal remains a challenge. Water contamination at the household level is a acknowledged concern for PAP, Leogane, and Jacmel. This refers to the observation that although the water provided from the spigot has been well-chlorinated in most locations where available by agencies such as Oxfam, the Bangladesh protocols for water handling are not being observed. Fecal contamination of the water occurs between the spigot and the household.

Health Cluster has reported "no outbreaks" to WASH Cluster, which should invoke careful discussion of the limitations of that assertion given the tremendous challenges seen in official reporting. WASH indicates they are coordinating preparedness plans for possible epidemic diarrheal disease. WASH members have joined the HEAS as well, which integrates official and unofficial reporting mechanisms for infectious disease events between these communities. 

Social Order-Health Security Nexus.  Since the 1950s, Haitian society has demonstrated a tendency to deteriorate into civil unrest during times of political instability.  Triggers for incendiary riots have included flooding, where the social outcry is driven by the following cited issues:

• access to shelter;
• access to food and safe water; and
• perceived exposure to a higher risk of infectious disease

Multiple reports have highlighted escalating tensions related to the relocation process. HEAS has detected a cluster of suicide attempts, and HEAS members have reported seeing signs of possible automatic weapons fire in gunshot victims based on number of bullet wounds seen in the patients. Recently it was reported gangs in Cite Soleil were arming themselves to engage in conflict with the established government.

Meteorology.  Conditions are optimized to support diarrheal disease and malaria transmission.  Researchers reported the 2010 Atlantic hurricane season will be more active than usual because of warm sea temperatures. The moderating El Nino conditions in the Pacific were likely to dissipate by Summer creating a very active season. Predicting likelihood of 15 named storms between June 1 and Nov. 30 - four of those major hurricanes. The team also predicts a 58 percent chance of a major hurricane tracking into the Caribbean (the long-term average is 42 percent).

Medical Response Grid Status.  Should an infectious disease crisis become manifest, the risk of inundation and overwhelming medical logistics during a rapid response campaign remains high.

Current Advisories and Situation Status.

Op Notes- Disruptors

Diarrheal Disease.  The situation is currently STABLE, with no signs of an increase in diarrheal disease. To-date, diarrheal disease events have not been reported higher than an IDIS Category 1.

Seasonal spring rains have come to Haiti and are compromising the IDP camp environment. The alert level was escalated to a WARNING status on 3 APR and is maintained due to

1. Optimized environmental conditions to support disease transmission.

2. Continuing decrease in available pediatric medical care resources

3. Questionable agility in medical logistics chain for epidemic response

4. Faltered syndromic surveillance capacity

5. Substantial population shifts related to relocation

6. Ongoing challenges to water / hygiene / sanitation efforts

The situation represents a high risk for a Category 3 or 4 pediatric diarrheal disease event to develop.  

Malaria (falciparum).  We elevated the alert status to a WATCH on 21 APR for malaria based on multiple credible reports of steadily INCREASING prevalence in multiple sites in PAP.  This finding was not unexpected and now represents an IDIS Category 2 event given there is an organized response to this report.

We assess malaria cases will increase due to the combination of an increase in vector container breeding sites in the garbage piles at the camps and crowding of people.  We do not expect the case counts to rise quickly enough to represent a disruptive event (i.e. crisis).  However we have changed our assessment to MODERATE risk for triggering a crisis due to the potential of an accumulation of cases high enough to eventually strain the medical infrastructure.  The MENTOR Initiative has indicated medical countermeasure stockpiles are present and ready to support crisis response.

We do not expect malaria to escalate beyond an IDIS Category 2 event, however we will monitor closely and reassess as appropriate.

Pandemic H1N1.   The trend of acute respiratory infections has been STABLE since last report.  We are unable to determine to what extent, if any, the current reporting of acute respiratory infection and pneumonia represents pH1N1. To-date, acute respiratory infection events have not been reported higher than an IDIS Category 1.

Per ground truth, a transmission wave has not been observed in Haiti since the start of the pandemic.  It is recognized the Haitian Ministry of Health first reported laboratory-confirmed pH1N1 on July 15th, 2009 in a native Haitian and two Chilean MINUSTAH soldiers, without indication of epidemic transmission.  Cuba recently announced they were seeing an increase in pH1N1 activity, prompting a vaccination campaign.  We are monitoring closely.

While a mild disease for the vast majority of those affected, we are concerned about the current nutritional status of the population, overcrowding in the IDP camps, and the coming rains encouraging higher contact rates in the tents.  It is difficult to anticipate if and how many cases will be seen.  The concern relates to the presence of only one PICU in PAP that is easily overwhelmed if there is a demand for ventilatory care, and the overall difficulty in access to medical care throughout much of the city.  Similar concerns pertain to the population of pregnant mothers.  As we noted across many countries, lack of access to medical care was often associated with poor clinical and community outcomes.  The population of Haiti has not been vaccinated for pH1N1.

According to MSPP, children less than 5 years of age comprise more than half of all acute respiratory infections reported. PCR testing capability has arrived in PAP, and discussions have begun to investigate the high prevalence of acute respiratory infection that has been consistently reported since the earthquake. HEAS has noted several fatalities due to pneumonia. It is recognized H1N1-bacterial pneumonia was documented during the pandemic in other countries and was a cause of death. All H1N1 tests conducted thus far in Haiti have been negative, however a rigorous assessment has not occurred.  MSPP will not be advocating a vaccination campaign for pH1N1.

Influenza outbreaks and epidemics may be observed in tropical climates.  As an example, in 2002, Madagascar experienced an outbreak of A/H3N2.  From August to September, authorities documented 30,304 cases and 754 fatalities from 13 of 111 health districts and 4 of 6 provinces.  Most of the illnesses occurred in rural areas, and an estimated 95% of cases were not reported.

We assess if pH1N1 were to pose a problem in the minor rainy season, it would present as focal outbreaks that may be difficult to control. We estimate these events, in a worse case scenario, would represent an IDIS Category 3. 

Dengue.  The current situation is STABLE.  Dengue events have not been reported in Haiti higher than an IDIS Category 1.

The above risk chart for disruptor agents reflects our separate concern for dengue fever versus dengue hemorrhagic fever.  We believe uncomplicated dengue fever being observed in responders will be an increasing problem as we enter the minor rainy season, with an expected peak in the latter half of the year.  This is not a concern for the Haiti population due to protective genetic factors observed in African populations and because this is considered a normal, endemic, and expected seasonal pattern from the Haitian point of view.  Dengue hemorrhagic fever is not generally observed in Haitians, but responders who are in Haiti for prolonged periods of time that allow opportunity to be infected with multiple serotypes of dengue may be a greater risk for dengue hemorrhagic fever. 

In summary, we do not assess dengue to represent a concern as a true disruptor in Haiti, however we are monitoring closely and will reassess as appropriate.

Op Notes- Other Infectious Disease of Public Health Concern

Anthrax.  The risk of a disruptive event involving gastroenteric anthrax is considered very low.  It is expected cutaneous anthrax cases will still be observed, as is expected and routine for May and June.  Two cases were diagnosed at the Port-au-Prince General Hospital several weeks ago.  Two suspected cutaneous anthrax cases were reported at the PAP General Hospital last month, reflective of an IDIS Category 1 event.  We assess the overall risk for anthrax cases has dropped significantly since USSOUTHCOM has engaged in an anthrax vaccination program for livestock in Haiti.  Should an anthrax event be reported, we do not expect it to exceed an IDIS Category 1.

Vaccine-Preventable Disease. Vaccinations continue, and we have adjusted our assessment to reflect the likelihood of achieving some degree of protective herd immunity.  MSPP, WHO, and UNICEF have reached an estimated 25% of the overall goal of 2M children to be vaccinated.  Measles has not been confirmed in Haiti.

Waterborne Disease.  Diarrheal disease, including typhoid, is covered above under "Disruptors" and is the top concern at present.  MSPP official syndromic surveillance picked up two limited outbreaks of hepatitis A, reflective of an IDIS Category 1.

There continues to be an assumption cholera will be a serious problem in Haiti with the onset of the rainy season.  The true risk of cholera is assessed to be neglible because there has not been documented cases in Haiti in the last fifteen years (at least).  The appearance of cholera would have to be introduced by a foreign traveler to Haiti. 

Increased leptospirosis incidence has been observed in other countries during periods of heavy rainfall and flooding, and one military responder was reported to be infected.  This week several suspect cases of leptospirosis were reported at General Hospital-PAP, however laboratory confirmation was not done.  These event reached no higher than an IDIS Category 1.  This is a current concern in Haiti as flooding has already been documented in Les Cayes.  We do not assess leptospirosis to be a likely disruptor in the next 90 days, however we are monitoring closely and will re-assess as appropriate.

Other Vectorborne Disease.  West Nile virus is present in Haiti and is expected to largely present as febrile illness with the occasional neurological sequelae.  It is typically seen in the latter half of the year as temperatures optimize for transmission.  It is possible to see increased activity in June.  We do not assess West Nile to be likely a disruptor in the next 90 days, however are monitoring closely.

Other Respiratory-Transmitted Diseases.   Tuberculosis in its various forms of drug resistance has the potential to become a larger problem than it already was due to divestment and loss to follow up of tuberculosis patients from the sanitarium.  If they have joined IDP camps, the opportunity for transmission to others, including responders, is a risk.  We are concerned about adherence of proper infection control standards to protect responders.  Current crowding may favor increased transmission. 

We have seen documentation and death of a responder due to meningococcal meningitis.  Both tuberculosis and meningococcal meningitis may be transmitted in close, crowded conditions as it observed in the IDP camps.  Heavy sustained rain encourages more person to person contact.  Meningococcal meningitis transmission is typically favored by low humidity, however the effect of crowding cannot be discounted as a concern for increased transmission.  One of the HEAS partners have encouraged the consideration of malaria in the differential diagnosis.  In March, Praecipio sent an Intercept Team to a hospital reporting an apparent outbreak of meningitis that was laboratory confirmed to be pneumococcal meningitis. 

Other.  Rabies as a risk has declined significantly because the Ministry of Agriculture, in conjunction with NGO partners such as ARCH estimate a 70-75% vaccination coverage among free roaming companion animals in PAP.  USSOUTHCOM continues to support vaccination of rabies.

Operational Definitions

Infectious disruptor agent.  An infectious disease capable of triggering crisis or disaster conditions.

Infectious disease crisis: time-sensitive, non-routine organization-level decisions that may affect a local community’s activities of daily living. It is more common such decision-making falls within the roles and responsibility of a public health institution than a public or private hospital or individual healthcare provider. This becomes a community level decision-making activity in countries where there is no public health capacity.  The majority concern here is pediatric diarrheal disease in Haiti.

Infectious disease disaster: when crisis mode decision making by public health officials or institution fails to control the situation, either from an informational or response perspective and substantial social disruption associated with features of community disintegration occurs as a result.  The term "community disintegration" refers to the dissolution of a community as a social unit. This is classically exemplified by the evacuation of a village due to an uncontrolled epidemic. Ebola is the archetype disruptor capable of generating this kind of social response in undeveloped areas of Africa.  We do not consider any of the infectious disease in Haiti to represent potential disasters.

Warning.  Indication of increasing incidence of an infectious disruptor agent, with alignment of optimized conditions to support transmission. 

Watch. Indication of increasing incidence of an infectious disruptor agent, without alignment of optimized conditions to support transmission. 

Advisory.  Presence of an infectious disruptor agent reported. 

Infectious Disease Impact Scale (IDIS).  The IDIS is a model that serves as a guide to understanding the impact of acutely disruptive infectious disease events through the lens of disaster sociology.  Up to this point, event descriptors of infectious disease events have focused on use of terms like "outbreak" and "epidemic".  This is problematic in the operational setting when valid epidemiological data is often sparse or unreliable.  Here we consider a different perspective that focuses on the interface between an infectious disease hazard and indigenous vulnerability. 

IDIS Category 0.  Unreported infectious disease event.  Daily, routine infectious diseases are handled at this level, and provision of warning about these diseases is not deemed 'relevant'.

IDIS Category 1.  Reported infectious disease event.  The typical Category 1 infectious disease event reported by a community reflects a sensitivity to public health or medical significance.  No other significant features indicative of immediate public health or medical infrastructure impact, public anxiety, or civil unrest triggered by the event are noted.

IDIS Category 2.  Infectious disease event associated with routine organized response.  Category 2 events often reflect locally well-known diseases that nevertheless generate a demand for organization-level time-sensitive action.  This action is local routine. 

IDIS Category 3.  Infectious disease event associated with non-routine organized response.  Category 3 events are essentially the beginnings of a community crisis.

IDIS Category 4.  Infectious disease event associated with social disruption.  Category 4 events highlight when organized response has occurred, yet significant social disruption has been documented.

IDIS Category 5.  Infectious disease event associated with disaster indicators. 

IDIS Category 6.  Infectious disease event associated with apocalyptic indicators.